Posts Tagged ‘jaw implants’

Background: A variety of mandibular (jaw) implants to improve the shape of the lower third of the face exist. They work very well for horizontal chin augmentation or lateral jaw angle enhancement. When the two are put together, a great improvement in the jaw line and shape can be achieved. But standard implants do not exist for treating an uncommon deficiency of the jaw, that of vertical deficiency. Lengthening of the lower face heretofore could not be done with implant techniques.

Case Study: A 55 year-old male wanted improvement in his ‘weak jawline and chin.’ It could be seen in profile that his chin was not that horizontally short. The lower third of his face was vertically short from front to back. This was the result of a mandibular deficiency which was detected in his bite, he had a complete 100% overbite. (lower jaw sits completely inside his upper) His mandible was overclosing thus giving him a vertically short lower jaw. While orthognathic surgery and orthodontics are the standard approach for this problem, he was understandably reluctant for that treatment at his age and state of his teeth. No standard jaw implant exists for this problem.

Using a 3-D CT scan of his mandible, a wrap around vertical lengthening jaw implant was designed in acrylic. The implant dimensions were based on facial measurements and his aesthetic desires. The acrylic mock-up was then sent to the manufacturer to be formally made and sterilized in silastic. (silicone rubber) This process took three weeks to complete.

The implant was then inserted onto the lower border of his jaw through a submental incision under the chin. There was no need for any dissection done inside the mouth. The soft tissues were elevated off of the bone around the chin and back to the jaw angle. The implant was then slide into place and secured to the bone with titanium screws. This procedure took one hour to complete under general anesthesia.

The increase in lower facial height and chin prominence was immediate. He reported some soreness but very little actual pain. It took about three weeks for all of the swelling to subside. He was ecstatic about the result and the change in his facial appearance was very positive. While this approach cost twice as much as a standard chin or jaw angle implant surgery, they were inadequate for what his face really needed to be in better proportionate balance. (vertical augmentation)

Case Highlights:

1)There is no standard off-the-shelf implant for vertical shortness of the chin or lower jaw.

2)Custom facial implants can be fabricated off of 3-D CT scans to fit specific bone deficiency needs. A wraparound mandibular implant is one such example of a successful custom facial implant.

3)Vertical lengthening of the jaw line and chin can have a powerful influence on increasing the strength and masculinity of the lower face in men.

Synthetic implants are the only method for increasing the size and prominence of the jaw angles. Placed over the junction of the posterior and inferior mandibular borders, the implant’s design and shape can help make the jaw angle’s definition more pronounced. By so doing, particularly when done on both sides, the width of the back of the jawline is increased creating a stronger and more masculine facial appearance.

Like any implant surgery, proper sizing and placement of the implant is essential for a good outcome. Jaw angle implants are available from only a few manufacturers with limited designs and sizes. Most commonly, the implant is designed close to an L-shape with about 4.5 cms of vertical height and horizontal length to it and no greater than 6 to 8mms in width. At these dimensions, the implant can certainly fit onto most jaws angles without being oversized. If measurements are taken on each patient, there is never a problem with fitting these implant sizes to the jaw, even in women.

My experience has been, however, that even the largest jaw angle implant commercially available (silicone) may be too small for most men. While they do make a difference, particularly when done bilaterally, some of my patients certainly comment thaty they wish they were bigger and provided even more definition. While it is possible to double stack jaw angle implants on top of each other (larger one against the bone and a smaller on top), I advise against this due to a high likelihood of shifting and displacement. (unless one can get double screw fixation on both sides) For this reason, I haved use a SAM (Gore-tex) block and carve out my own implant sizes which can be made bigger. This is more expensive than silicone rubber implants but is more effective when bigger sizes are needed. These Gore-tex blocks are also not as smooth and slippery as silicone and this increased frictional gripping is also helpful when one can not get or does not want to place screws for fixation.

When vertical jaw angle lengthening is needed, the only option is a Medpor jaw angle implants. Implant sizes go up to 11mms in width and 10mms in vertical lengthening which is more than adequate for most patient’s aesthetic needs. But some patients need more vertical lengthening than 10mms. To achieve greater than that amount, a custom implant design manufactured off of the patient’s 3D CT scan and model is needed.

Better jaw angle implant designs and sizes are needed, particularly in silicone materials. But until these are commerically available, ‘custom’ designed implants need to be used.

Facial asymmetry exists whenever one side of the face does not match the other in size and shape. The most common reason this occurs is due to different development patterns of the underlying facial bones and is most commonly seen in people who have some facial bone development issues such as cleft lip and palate and other craniofacial birth defects. Sometimes it may just be soft tissue only and the facial bones are fairly symmetric. But aside from these types of patients, some people merely have a light or mild facial asymmetry of which the cause is not obvious or will ever be known. In essence, it is just you.

In many cases of facial asymmetry the most common finding or cause is that the lower jaw is different between the two sides. Because the lower jaw is moveable (the only facial bone to do so) and has an L-shape in the back above which the jaw joint hinges, it is the one facial bone that is most prone to having differences between the two sides. Most commonly, these differences are back at the angle area and along the jawline that comes forward. This can create a very visible difference between the jawlines when looking straight forward. It is the most common type of facial asymmetry that I see. Sometimes I will see someone who has a crooked chin, where the chin point if offline, but the origin of the crooked chin usually comes from differential jaw growth between the two sides.

In cases of facial asymmetry it is initally important to make sure that the jaw asymmetry is not best corrected by actually moving the whole jaw and putting the teeth into a better bite relationship. If one is young and the jaw asymmetry is significant, how the teeth come together will determine if this is the best long-term solution. But assuming that jaw bone movement is not a good solution, the more common approach is to correct it with the placement of implants.

Jaw angle and jawline implants can be fairly simple methods of improving jaw asymmetry. These implants are almost always placed through inside the mouth. Off-the-shelf jaw angle implants exist but there is no off-the-shelf jawline implant. Jawline implants have to be fashioned at the time of surgery, usually out of a block or thick sheet of semi-soft material. (Gore-tex or SAM is what I prefer) The key to success with implant augmentation is to be certain of exactly where the jaw asymmetry is. Implants will do little good if they aren’t in the area of bone deficiency or asymmetry. Sometimes this is obvious by feel, other times it may be better to get a 3-D CT scan and have an exact skeletal image to work off of. In rare cases, I have even had a 3-D model made from the CT scan and custom-fabricated the shape of the implants prior to surgery. This is the most exacting method but also the most costly.

When having implants placed for any type of facial asymmetry it is important to walk into surgery with the understanding that the outcome will be better…but not perfect. Surgical facial augmentation with implants is as much an art as it is an exact science.

A more defined jaw angle is a not uncommon request of men, particularly younger men. I am seeing more of these patients recently than ever before. This is presumably driven by the desire for increased facial angularity and jaw line definition as seen in many male models. Surprisingly, I have also seen a few women with the same request although the female models that I have seen with this look (surgically created or natural?) look a little cartoonish to me.
Either male or female, the procedure is the same. An intraoral incision is used along the back part of the jaw. The large masseter muscle is lifted up along the entire angle of the jaw. The only ‘difficult’ part of a jaw implant angle procedure, in my opinion, is in the selection of the type of implant material (silicone rubber vs. polyethylene (Porex) and the exact style and size of the implant. There are theoretical differences between silicone vs polyethylene but, in the big picture, I am not sure any real differences exist in terms of postoperative outcome. I think the plastic surgeon should use whichever implant material thay are most comfortable. Whether to drop the existing jawline by an extended implant or simple along the current jawline to be widened is another decision. I found that most of the time an extended implant that lowers the jawline is most useful in those patients who have an ill-defined jawline that is both narrow and obtuse in angularity. Many men will get an extended style of implant, the few women I have done get a little increased width only. Whatever jaw implant is chosen and placed, it is very important to secure it in place with a screw or two. The only complications I have ever seen with jaw angle implants has been implant migration toward the incision. This risk is completely eliminated by secure screw fixation.
After surgery, there is a fair amount of discomfort due to muscle trismus and swelling. Unlike any other facial implant, jaw angle implants produce the greatest amount of discomfort and dysfunction. (difficulty with opening your mouth for a few weeks) However, jaw angle implants produce a nice lower profile change that is second only to what a chin implant can do. Sometimes, for maximum effect, jaw angle implants and chin implants may be done together to accentuate the entire jawline.
Dr. Barry Eppley

The facial features most associated with masculinity is the chin and jawline. A stronger chin and jawline conveys increased masculinity, smaller chins and ill-defined jawlines convey timidity and weakness. While this perceptions may not always be true (and often aren’t), they certainly help create a first impression by their appearance. In today’s plastic surgery, newer generation implants and fillers make this look possible more than ever before.Chin implants have really evolved over the past decade with many new styles and sizes. The most important change has been that they have been extended in their shape rather than small ‘buttons’. The idea is to have an enhanced chin that flows better into the surrounding jaw. This requires an implant that ‘extends’ back from the chin to create a smooth transition from the augmented chin to the back of the jaw. These newer implants are longer and more tapered at the ends, although they can still be placed through a small incision right under the chin. Because they extend back further they give an enhanced but natural appearance to the chin. This is achieved by filling in the jawline between the chin and the back of the jaw, slightly widening the anterior jawline making the overall look more balanced. In addition to jawline width, chin and jawline height can also be lengthened by having a ‘wrap-around’ implant that extends lower than the existing edge of the bone. Prior to these type of implants, only cutting the bone or bone grafting could have achieved this look. This increases the height of the lower third of the face, a very male-enhancing effect.
New implant options also exist for bolder cheekbones and more square jaw angles. Small cheekbones generally are not as obvious as a smaller chin but the effect on the appearance of the face is just as real. Small cheek bones create a flatter facial appearance or even a longer thin face look. Several styles of cheek implants exist to fill out different areas of the midface, from creating higher cheekbones to improving that sunken cheek look. Cheek implants are placed through an incision in the mouth so there is no scarring. A more square and well-defined jaw angle is a very masculinizing look and can only be created with implants. Jaw angle implants can eitehr widen the back of the jaw, make it more longer and more square, or both. Like cheek implants they are placed inside the mouth so scarring is never any issue.
It would not be uncommon to perform several areas of facial enhancement in the male to get the overall look that they want. Since an appreciation of facial shape and how the different areas can be changed and how they would look from implants mandates that computer-imaging be used. I find it usually takes at least two consultations to thoroughly cover all the options and make sure the patient has complete understanding of the facial look that they desire.
Dr Barry Eppley

For those male patients who desire a more square and angular facial appearance, the mandibular angle or jaw angle implant has become a popular facial implant option. By squaring off and extending the junction of the back and lower borders of the mandible (jaw), the appearance of the jaw becomes wider and more square. This type of look is often desired by younger males, particularly those interested in or already in the modeling field. It is also a very helpful procedure for those patients, male or female, with weaker jaw appearances or jaw asymmetry. I have placed as many mandibular angle implants for jaw asymmetries (one jaw side is very different than the other) as I have for bilateral (both sides) cosmetic enhancements.

In my practice here in Indianapolis, I discuss mandibular angle enhancement through the use of these implants. There are no practical bone-moving procedures for cosmetic enhancement of the mandibular angle, so implants are always used.While mandibular angle implants are available in different materials, I prefer the use of solid silicone (rubber) cheek implants, which are by far the most commonly used. They are soft, flexible, and slide easily into place along the side of the lower jaw. A mandibular angle implant is inserted through an incision in the mouth along the bone in the back part of the jaw. This leaves no visible scar. While it can be inserted through a skin incision in the neck, I have never done so. The mandibular angle implant is slide along the side of the back part of the lower jaw into its position over the edge of the bone. Usually a mandibular angle implant is held in place simply by the pocket into which it is placed. Occasionally, I will use a metal screw to secure the implant to the bone. This screw fixation method can eliminate one of the very few complications of mandibular angle implants, that of shifting position after surgery causing jaw asymmetry and loss of the desired .While any implant (foreign-body) has some risk of infection, mandibular angle implant infections are quite uncommon.

Enhancing the jaw angle with an implant is the least performed facial implant procedure, compared to cheek and chin implants. The goal of a mandibular angle implant is to produce a fullness to the back part of the lower jaw, resulting in a more square facial appearance. There are only a few variations in the styles of mandibular angle implants. The most basic differences in mandibular angle implants is in the amount of extension that can occur from the edges of the bone, both in the back edge as well as the lower edge. Also, different width thicknesses are available, dependent upon how much increase in width of the jaw angle is desired.

Mandibular angle implants are usually done alone but I have also performed them in conjunction with chin and cheek implants. The most powerful way to masculinize a male’s face is the combination of mandibular angle, chin, and cheek implants all done at the same time.

In the pursuit of improved facial balance and shape, the use of solid facial implants is a simple and proven method. While there are facial implants made from different materials that can be used, the use of solid silicone (rubber) chin, cheek, nose and jaw implants are by far the most commonly used. They are soft, flexible, and slide easily into place on top of facial bones. These type of facial implants are placed deep to the skin down at the bone level. Since they are solid, not gel-filled, there is no risk of implant leakage or breaking. All facial implants can be inserted through very discrete incisions that often leave no visible scars on the face. While any implant (foreign-body) has some risk of infection, facial implants infection is quite uncommon.

Enhancing the chin with an implant is the most commonly performed facial implant procedure. With a small incision under the chin, a chin implant can be easily put into place, bringing the chin forward so that it is in balance to the nose and lips. Unlike the old style ‘button’ chin implant, there are many different styles of chin implants today. From curved styles to a more box shape, to those chin implants with a central dimple, there are many options to custom tailor a chin implant to fit most patient’s faces. Usually the chin implant is sutured into place, a metal screw can be driven through the implant to the bone. This screw fixation method can eliminate one of the very few complications of chin implants, that of shifting or changing position after surgery causing chin asymmetry. Chin implants are commonly in conjunction with other facial procedures including rhinoplasty, neck liposuction, and facelifts.

Cheek implants also have a variety of styles, allowing fullness to be gained over the prominence of the cheekbone, filling out the hollow underneath the cheekbone, or allowing more fullness to be gained up to the side of the nose. By going through the mouth under the upper lip, there is no facial scarring. Cheek implants help bring fullness to a flat cheeks, help camouflage a prominent nose, or restore facial fat atrophy lost in HIV disease. Metal screw fixation seems to be of particular importance as the cheek implant is really sitting ‘on the side of the cliff’ so to speak and, therefore, is more prone to the risk of moving out of place after surgery.

Jaw implants of the mandibular (jaw) angle are relatively new. Jaw implants are designed to ‘square’ the face at the jaw angle for a more masculine look or to correct facial asymmetry if jaw development is different between the two sides of the face. Swelling and recovery after jaw angle implant placement is greater than with chin and cheek implants as the big chewing muscles must be lifted up to put the jaw angle implant in place. This causes some soreness in opening the mouth for several weeks after surgery.

In some cases, the use of different implants in the same patient, such as a chin and jaw angle implants in a male, can provide dramatic changes in one’s facial appearance. Facial implants are a powerful tool, that is simple and usually uncomplicated, to achieve facial enhancement.

Dr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.